The disturbed pt Flashcards
Example of organic mental DO
acute organic brain syndrome ______
chronic organic brain syndrome _____
(delirium)
dementia
Psychoactive and substance use disorders
1
2
3
- toxic states
- drug dependency
- withdrawal states
_____ affects 15% of people over 65 and can mimic or complicate any other illness, including delirium and dementia.
Depression
The diagnosis of dementia can be overlooked: a Scottish study showed that _____of demented patients were not diagnosed by their GP
80%
The key feature of dementia is
impaired memory
Hallucination guidelines: —\_\_\_\_\_\_ psychoses e.g. schizophrenia — \_\_\_\_\_: almost always organic disorder — \_\_\_\_\_ temporal lobe epilepsy — \_\_\_\_\_ cocaine abuse, alcohol withdrawal
Auditory:
Visual
Olfactory:
Tactile:
A term used for both senile and presenile dementia, which has characteristic pathological degenerative changes in
the brain.
AD
The mental functions of perception, thinking
and memory. It is the process of ‘knowing’.
cognition
Repeated, stereotyped and seemingly
purposeful actions that the person feels compelled to carry out but resists, realising they are irrational (most are associated with obsessions).
Compulsion
Disorientation in time, place and person. It
may be accompanied by a disturbed conscious state
Confusion
The process by which thoughts or
experiences unacceptable to the mind are repressed and converted into physical symptoms.
Conversion
also termed ‘toxic confusional state’)
A relatively acute disorder in which impaired
consciousness is associated with abnormalities of perception or mood
Delirium
Abnormal, illogical or false beliefs that are
held with absolute conviction despite evidence to the
contrary.
Delusions
An acquired, chronic and gradually
progressive deterioration of memory, intellect and personality.
Dementia
______ or early onset dementia is dementia under 65 years of age.
______refers to older patients (usually over 80 years
Presenile dementia
Senile dementia
A psychological disorder in which
unpleasant memories or emotions are split off from consciousness and the personality and buried into the unconsciousness
Dissociation
An alteration in the awareness of
the self—the person feels unreal.
Depersonalisation
Disorders of perception quite divorced
from reality
Hallucinations
False interpretations of sensory stimuli such
as mistaking people or familiar things.
Illusion
Recurrent or persistent thoughts, images
or impulses that enter the mind despite efforts to exclude them
Obsessions
The conversion of mental experiences
or states into bodily symptoms, with no physical causation.
Somatisation
The sudden onset of delirium may suggest
1
2
3
angina, myocardial infarction or a cerebrovascular accident
In the elderly in particular, fluid and electrolyte
disturbances, such as dehydration, ___________, can cause
delirium
hypokalaemia, hyponatraemia and hypocalcaemia
Sedation:
Avoid intramuscular ____ because of poor absorption.
diazepam
Be cautious of intravenous _____
(Hypnovel) in such patients because of the risk of respiratory depression
midazolam
Avoid benzodiazepines in patients with
respiratory insufficiency. ______ is an
alternative
Haloperidol
Adverse effects of sedatives:
• respiratory depression
• hypotension
________
_______
- dystonic reactions, including choking
* neuroleptic malignant syndrome
Benzodiazepines are generally the drugs of first choice over antipsychotics in _______
tranquillisation
Oral BZD sedatives:
Oral medication
diazepam 5–20 mg (o), repeated every 2–6 hours (max: 120 mg/24 hours)
or
lorazepam 1–2 mg (o), repeated every 2–6 hours (max: 10 mg/24 hours
If sedation is not achieved with DZP and Loraz, add an antipsychotic medication e.g.
olanzapine 5–10 mg initially or
risperidone 0.5–1 mg initially
______is similar to
haloperidol but more sedating
Droperidol
SE with Droperidol
potentially fatal laryngeal dystonia with high
doses
How to manage acute dystonia with Droperidol
benztropine 2 mg IM.)
Diagnosis of delirium requires evidence of:
A________
B________
C A change in cognition: • perceptual disturbance • incoherent speech • disorientation • memory impairment/deficit
D A & C not better explained by another disorder
E Evidence of a cause
A Disturbance of consciousness, attention and
awareness
B Clinical features appearing over a short period
Delirium cause
Features include hyperactivity, marked thought disorder, vivid visual
hallucinations and very disturbed behaviour
Anticholinergic delirium
Consider alcohol withdrawal and give a trial of_______when the cause of delirium is unknown
thiamine
Delirium Mx:
For psychotic behaviour
1
2
haloperidol 0.5 mg (o) as a single dose
or
olanzapine 2.5–10 mg (o) daily in 1 or 2 doses
Delirium Mx:
If oral administration is not possible or when
parenteral medication is required (cover with
benztropine 2 mg (o) or IM):
haloperidol 0.5 mg IM as single dose
or
olanzapine 2.5 mg IM as single dose
Delirium Mx:
For anticholinergic delirium:
tacrine hydrochloride 15–30 mg with caution by
slow IV injection (an antidote
______ is the presence of the mental state where appreciation of reality is impaired as evidenced by the presence of typical psychotic symptoms such as delusions, hallucinations, mood disturbance and
bizarre behaviour
Acute psychosis
DSM for Schiz
Two or more of following, each present for a
significant portion of time during a one-month period
1
2
3
4
5
1 delusions 2 hallucinations 3 disorganised speech 4 grossly disorganised or catatonic behaviour 5 negative symptoms e.g. flat effect
refers to a group of severe psychiatric illnesses characterised by severe disturbances of emotion, language, perception, thought processes, volition and motor activity
Schizophrenia
Positive Sx of Schiz
— delusions
— hallucinations
— thought disorder
— disorganised speech and behaviour
Negtaive Sx of Schiz
— flat affect — poverty of thought — lack of motivation — social withdrawal — reduced speech output
Cognitive Sx of Schiz
— distractibility
— impaired working memory
— impaired executive function (e.g. planning)
— impaired insight
Mood DO of Schiz
— mania (elevation)
— depression
Drugs associated with Schiz
- amphetamines
- hallucinogens (e.g. LSD)
- marijuana
How to start of antipsychotic in Schiz
Start with a low dose and titrate upwards at a rate and to a level that is optimal for the
patient. Patients with a first psychotic episode may respond to lower than usual doses.
First line of anti psychotics 1 2 3 4 5 6 7 8 9
amisulpride 100 mg nocte asenapine 5 mg sublingual bd aripiprazole 10 mg once daily olanzapine 5 mg nocte paliperidone 3 mg once daily quetiapine 50 mg bd → 200 mg bd (by day 5) risperidone 0.5–1 mg nocte → 2 mg nocte sertindole 4 mg (o) once daily ziprasidone 40 mg bd → 80 mg bd
Options If no response after 4–6 weeks
• an alternative second-generation agent
or
• a first-generation antipsychotic such as:
chlorpromazine 200 mg once daily → 500 mg
haloperidol 1.5 mg once daily → 7.5 mg
trifluoperazine 2 mg bd
What parenteral medication to be given in acute care?
haloperidol 2.5–10 mg IM, initially, up to
20 mg in 24 hours, depending on the response
or
olanzapine 5–10 mg IM initially (do not use
with benzodiapines concurrently)
_______ is not recommended for
long-term use because of photosensitivity
reactions
Chlorpromazine
Schiz Tx
Use ______ preparations if compliance is a
problem
depot
Schiz Tx
________ may help the agitated patient, especially if catatonic.
ECT
Movement disorders from antipsychotic
medication
- Usually bizarre muscle spasms affect face, neck, tongue and trunk
- Oculogyric crises, opisthotonos and laryngeal spasm
What movement DO
Acute dystonias
Tx of acute dystonia
benztropine 1–2 mg IV or IM
Movement disorders from antipsychotic
medication
- Subjective motor restlessness of feet and legs
- Generally later onset in course of treatment
Akathisia
MX of Akathisia
can use oral propranolol, diazepam or
benztropine as a short-term measure
_______is a syndrome of abnormal
involuntary movements of the face, mouth, tongue, trunk and limbs
Tardive dyskinesia
Antipsychotics Tx
high temperature, muscle rigidity,
altered consciousness.
Neuroleptic (antipsychotic) malignant
syndrome
Management of NMS
bromocriptine 2.5 mg (o) bd, gradually increasing to 5 mg (o) tds
and
dantrolene 50 mg IV every 12 hours for up to
7 doses
Various psychotrophic agents, particularly the
________ are prone to cause the adverse effect of prolongation of the QT interval with potential
severe outcomes
phenothiazines,
__________– disorder has one fully fledged manic or
mixed episode and usually depressive episodes.
Bipolar I
_________-disorder is defined as a major depressive
episode with at least one hypomanic episode but no
classic manic episodes
Bipolar II
T or F
The symptoms of mania may appear abruptly.
T
Ineherent features of mania
• reckless behaviour, overspending • hasty decisions (e.g. job resignation, hasty marriages) • impaired judgment • increased sexual drive and activity • poor insight into the problem • variable psychotic symptoms—paranoia, delusions, auditory hallucinations
____________-is the term used to describe the
symptoms of mania that are similar to but less severe
(without criterion C) and of shorter duration
‘Hypomania’
Management of acute mania
This is a medical emergency requiring hospitalisation
for protection of both family and patient.
Involuntary admission is usually necessary
MX of acute mania
Most effective?
A recent metaanalysis
indicates that antipsychotics are the most
efficacious drugs.
First line of drugs for acute mania
First line:
olanzapine 5 mg (o) nocte initially
or
risperidone 0.5–1 mg (o) nocte initially
2nd line of drugs for acute mania
haloperidol or other first-generation
antipsychotic
or
lithium carbonate 750–1000 mg (o) daily in 2 or 3
divided doses increasing according to serum levels
or
sodium valproate 200–400 mg (o) bd initially
or
carbamazepine 100–200 mg (o) bd initially
Failure to respond to treatment
• combine drugs e.g. second-degree
antipsychotic + lithium
• _________ is of proven benefit for recalcitrant patients
ECT
When to start prophylaxis for recurrent BPD
consider medication if two or more episodes of either
mania or depression in the previous 4 years
Recurrrence rate of BPD
90%
Recommended prophylactic agents for BPD
lithium 125–500 mg (o) bd then adjusted or second-generation antipsychotic agent or (if depression prominent) lamotrigine or carbamazine or sodium valproate
A US study recommended ______- as the
prime mood stabiliser
lithium
SE of Lithium
— a fine tremor
— muscle weakness
— weight gain
— gastrointestinal symptoms
Mx of BPD Depression
lithium, valproate, carbamazepine, quetiapine,
lamotrigine or olanzapine
plus
an antidepressant (e.g. SSRI, SNRI or MAOI
Antidepressants are usually withdrawn within 1–2
months because of a propensity to precipitate ______–
mania.
_______patients usually recover but proceed to
have further episodes of depression or mania
Bipolar I
________-is characterised by a
preoccupation with the belief that some aspect
of physical appearance is abnormal, unattractive
or diseased
Body dysmorphic disorder
How to Mx body dysmorphic DO
Patients may be helped by counselling and
psychotherapy including CBT
depression can be confused with dementia
or a psychosis, particularly if the following are present
- psychomotor agitation
- psychomotor retardation
- delusions
- hallucinations
Questions to ask in assessment of depression
Is it primary? Is it part of BPD? IS it secondary to an illness? is pt psychotic? is pt at risk for suicide?
Barbiturate withdrawal is a very serious,
life-threatening problem and may be encountered
in elderly people undergoing longstanding____
hypnotic
withdrawal.
Sx of Barbiturate dependence
Symptoms include anxiety, tremor,
extreme irritability, twitching, seizures and delirium.
Withdrawal Sx for BZD dependence
include anxiety, restlessness, irritability, palpitation
and muscle aches and pains, but delirium and
seizures are uncommon except with very high
doses.
What is the dx
Clinical features: • short attention span • distractibility • overactivity • impulsiveness • antisocial behaviour
ADHD
Mania is seldom diagnosed before puberty. \_\_\_\_\_\_\_\_\_may present (uncommonly) with symptoms of mania or hypomania.
Adolescents
Schiz in children
Schizophrenia is rare before puberty. The criteria for
diagnosis are similar to adults:
• delusion
• thought disorder
• hallucinations
• 6 months or more of deterioration in functioning
Aggression and irritability can be a feature, especially
during adolescence
Autism
______ has been defined as a ‘propensity to
cause serious physical injury or lasting psychological
harm to others’ and, in the context of the mentally
abnormal, ‘the relative probability of their committing
a violent crime
Dangerousness
RF fo violent conduct 1 2 3 4 5 6 7 8
- Schizophrenic psychoses
- Morbid jealousy
- Antisocial personality disorder
- Mood disorder:
- Episodic discontrol syndrome
- Intellectual disability combined with personality
disorder and behavioural disturbances - Alcohol abuse or dependency
- Amphetamine or benzodiazepine abuse
In Australia suicide is the second most common
cause of death between the ages of _________–. Children as young as 5 years of age have
committed suicide.
11 and 25 years
RF for suicide
1 Psychiatric disorders:
a
b
c
2 Personality traits:
• impulsiveness and aggression
• affective disorder and alcohol abuse in adults
• schizophrenia
• depression and conduct disorder in young
people
RF for suicide
Environmental and psychosocial factors:
a
b
c
- poor social supports
- chronic medical illness (e.g. AIDS)
- significant loss
RF for suicide
4 Family history and genetics (both nature and
nurture):
a
b
5 Biological factors:
a
- emulation of relatives
- specific ethnic groups in custody
• possible serotonin deficiency
_________ is attempted suicide; in many cases
patients are drawing attention to themselves as a ‘plea for help
Parasuicide
In practice the personality disorders of most
concern are those that present with __________, either verbal or physical, particularly if a suicide or homicide threat is involved
hostility
Characterisitics of personality DO
• lack of confidence and low self-esteem
• long history from childhood
• difficulties with interpersonal relationships and
society
• recurrent maladaptive behaviour
• relatively fixed, inflexible and stylised reaction to
stress
Main cluster of personality DO
1
2
3
- Withdrawn
- Antisocial
- Dependent
Withdrawn Personality DO subtypes
Paranoid
Schizoid
Schizotypal
Antisocial personality DO subtype
psychopathic)
Histrionic (hysterical)
Narcissistic (‘prima donna’)
Borderline (‘hell-raiser
Dependent personality DO subtype
Avoidant (anxious)
Dependent
Obsessional (obsessive–
compulsive)
Suspicious, oversensitive, argumentative, defensive,
hyperalert, cold and humourless
Paranoid
Shy, emotionally cold, introverted, detached, avoids close relationships
Schizoid
Odd and eccentric, sensitive, suspicious and
superstitious, socially isolated, odd speech, thinking and
behaviour. Falls short of criteria for schizophrenia
Schizotypal
Impulsive, insensitive, selfish, callous, superficial charm,
lack of guilt, low frustration level, doesn’t learn from
experience, relationship problems (e.g. promiscuous),
reckless disregard for safety of self and others
Antisocial (sociopathic,
psychopathic)
Self-dramatic, egocentric, immature, vain, dependent,
manipulative, easily bored, emotional scenes,
inconsiderate, seductive, craves attention and excitement
Histrionic (hysterical)
Morbid self-admiration, exhibitionist, insensitive, craves
and demands attention, exploits others, preoccupied
with power, lacks interest in and empathy with others,
bullying, insightless
Narcissistic (‘prima donna’)
Confused self-image/identity, impulsive, reckless,
emptiness, ‘all or nothing’ relationships—unstable and
intense, damaging reckless behaviour, full of anger and
guilt, lacks self-control, uncontrolled gambling,
spending etc
Borderline (‘hell-raiser’)
Anxious, self-conscious, fears rejection, timid and cautious,
low self-esteem, overreacts to rejection and failure
Avoidant (anxious)
Passive, weak willed, lacks vigour, lacks self-reliance and
confidence, overaccepting, avoids responsibility, seeks
support
Dependent
Rigid, perfectionist, pedantic, indecisive, egocentric,
preoccupied with orderliness and control
Obsessional (obsessive–
compulsive
Procrastinates, childishly stubborn, dawdles, sulks,
argumentative, clings, deliberately inefficient and
hypercritical of authority figures
Passive–aggressive
Health-conscious, disease fearing, symptom
preoccupation
Hypochondrial
Pessimistic, anergic, low self-esteem, gloomy, chronic
mild depression
Depressive (dysthymic,
cyclothymic
The medical/psychiatric significance of personality DO
• maladaptive relationships with GPs and society
• problem of sexually dysfunctional lives
• risk of substance abuse and self-destructive
behaviour
• prone to depression and anxiety (usually low
grade)
• susceptible to ‘breakdown’ under stress
__________ is the result of a genetic template and
the continuing interaction of the person with outside
influences (peer pressures, family interactions,
influential events) and personal drives in seeking an
identity
Personality
________-tend to come to the attention
of GPs more frequently, with some individuals
representing ‘heart-sink’ patients because of
demanding, angry or aggressive behaviour.
The antisocial personality disorders (ASPD) group
1–2% of population
The
____________are typically withdrawn, suspicious
and socially isolated but fall short of a true psychotic
syndrome
withdrawn group
Problem with the withdrawn group
GPs have problems communicating with
them because they are often suspicious
In the ___________, which
may overlap with an anxiety state, the main features
are nervousness, timidity, emotional dependence
and fear of criticism and rejection
dependent and inhibited groups
They are frequent
attenders (the ‘fat file’ syndrome) and are often
accompanied by friends and relatives because of their
insecurity.
dependent and inhibited groups
The _____- and _______-disorders
in particular respond well to specific types of
psychotherapeutic intervention
borderline and narcissistic
The mood disorders are divided into ____ and_____
depressive
disorders and bipolar disorders
